Humana Medicare Advantage Preferred Provider Organization (PPO) and Private Fee-for-Service (PFFS) Members Can Choose "Primary Physician".

Humana's Medicare Advantage Preferred Provider Organization (PPO) and Private Fee-for-Service (PFFS) plans now give members the option to name a "primary physician" who will focus on their health care needs and coordinate their care when needed. As a result, health care providers may see a primary physician listed on Humana MA PPO and MA PFFS members' ID cards. We hope that this effort will encourage our members to actively engage in managing their health, well-being and benefits.

What does this mean for health care providers?

  • Members will select a primary physician as the person they want to coordinate their care.
  • The member's primary physician will be listed on the back of the member's Humana ID card.
  • Health care providers will continue to work as they do today regarding clinical management of Humana MA PPO and MA PFFS members.
  • If a patient chooses a new primary physician, the patient will receive a new member ID card that reflects the change.
  • Health care providers will not need a referral to see Humana MA PPO and MA PFFS members. (Referral requirements for MA HMO members have not changed.)
  • Humana MA PPO and MA PFFS members still have the freedom and flexibility to see the health care provider of their choice, regardless of specialty.
  • To facilitate continuity of care, it is critical that specialists' offices forward results of office visits and tests to patients' primary physicians. If information is not received, primary physicians' offices should follow up with the specialist to obtain results for the patient's medical records.

The Centers for Medicare & Medicaid Services (CMS) star ratings hold MA health plans accountable for their members receiving recommended preventive care services and timely access to care. We also have an obligation to help our members maximize their MA health plan benefits. We hope that, by selecting a primary physician, members will have the clinical support needed to facilitate coordination of care.

Other Frequently Asked Questions and Answers

Q: Are patients with Humana MA PPO or MA PFFS coverage required to choose a primary physician?

A: No. Primary physician selection is an invitation, not a requirement. If the Humana MA PPO or MA PFFS members do not want to provide Humana with this information, that is their choice.

Q: What types of physicians can be listed as a primary physician?

A: Primary physicians are typically (but are not required to be) one of the following:

  • Family practitioners
  • General practitioners
  • Internists
  • Obstetricians/Gynecologists
Q: Why should health care providers encourage their patients to choose a primary physician?

A: We hope that this effort will encourage our members to actively engage in managing their health, well-being and benefits. We believe that choosing a primary physician will provide the following benefits for our members:

  • Regular check-ups and preventive care to avoid costlier care later
  • Central point for medical records
  • Monitoring and management of chronic conditions
  • Routine and urgent care
  • Medication coordination and management
  • Specialist recommendations
  • Follow-up care after a hospital stay
  • Preventive care to avoid costlier care later
  • Healthy lifestyle choice information
Q: How can a health care provider obtain a list of patients who have chosen him or her as their primary physician?

In order to receive a monthly roster report healthcare providers need to first request a roster from on Humana.com or Availity.com. Registration is only required one time.

To request a roster report on Humana.com: Once logged into the secure provider website Humana.com (registration required), choose "Resources," then "Request Medicare Member Roster" under the "Resources and Communications" heading. If more than one organization is associated to the tax ID on the user's account, the user will need to select an organization for which the report will be created. The user will need to complete the request form and choose "submit" in order to request the report.

To request a roster report on Availity.com: Once logged on to the secure provider website at Availity.com (registration required), choose "Administrative Reporting" then "Request Medicare Member Roster". The user will need to complete the request form and choose "submit" in order to request the report.

The first rosters are expected to be available around January 20, 2012. Future reports will be available after the 23rd of each month.

Please note the following important details:

  • When a report is ready to be accessed, a notification will be triggered through the BBS system. This is the same process used today for existing Service Fund downloads.
  • The notification inform the health care provider that the report is ready to view.
  • Once a health care provider receives the BBS notification, the roster report can be accessed by using the "Service Fund Download" link. To find this link, log into the secure provider website, choose "Resources," then "Service Fund Download" under the "Resources and Communications" heading.
  • These reports can also be accessed via Availity.com (select markets only, registration required). Once logged into Availity.com, choose "Administrative Reporting" and then "Service Fund Download."